Background The COVID-19 pandemic has disrupted healthcare services around the world, which may have serious implications for the prognosis of patients with acute cardiovascular disease. We conducted a systematic review to assess the extent to which health services related to the care and management of acute cardiovascular events have been impacted during the COVID-19 pandemic. Methods PubMed, MedRxiv and Google Scholar were searched for observational studies published up to August 12, 2020 for studies that assessed the impact of the pandemic on the care and management of people with acute CVD. Results In total, 27 articles were included. Of these, 16 examined the impact on acute coronary syndromes (ACS), eight on strokes, one on ACS and strokes, and 2 on other types of CVD. When comparing the COVID-19 period to non-COVID-19 periods, eleven studies observed a decrease in ACS admissions ranging between 40 and 50% and five studies showed a decrease in stroke admissions of between 12 and 40%. Four studies showed a larger reduction in non-ST-segment elevation myocardial infarctions (NSTEMI) compared to ST-segment elevation myocardial infarctions (STEMI). A decrease in the number of reperfusion procedures, a shortening in the lengths of stay at the hospital, and longer symptom-to-door times were also observed. Conclusions The COVID-19 pandemic has led to a substantial decrease in the rate of admissions for acute CVD, reductions in the number of procedures, shortened lengths of stay at the hospital and longer delays between the onset of the symptoms and hospital treatment. The impact on patient's prognosis needs to be quantified in future studies.

The impact of the COVID-19 pandemic on the care and management of patients with acute cardiovascular disease: a systematic review.

Background Excess mortality from cardiovascular disease during the COVID‐19 pandemic has been reported. The mechanism is unclear but may include delay or deferral of care, or differential treatment during hospitalization because of strains on hospital capacity. Methods and Results We used emergency department and inpatient data from a 12‐hospital health system to examine changes in volume, patient age and comorbidities, treatment (right‐ and left‐heart catheterization), and outcomes for patients with acute myocardial infarction (AMI) and heart failure (HF) during the COVID‐19 pandemic compared with pre‐COVID‐19 (2018 and 2019), controlling for seasonal variation. We analyzed 27 427 emergency department visits or hospitalizations. Patient volume decreased during COVID‐19 for both HF and AMI, but age, race, sex, and medical comorbidities were similar before and during COVID‐19 for both groups. Acuity increased for AMI as measured by the proportion of patients with ST‐segment elevation. There were no differences in right‐heart catheterization for patients with HF or in left heart catheterization for patients with AMI. In‐hospital mortality increased for AMI during COVID‐19 (odds ratio [OR], 1.46; 95% CI, 1.21–1.76), particularly among the ST‐segment–elevation myocardial infarction subgroup (OR, 2.57; 95% CI, 2.24–2.96), but was unchanged for HF (OR, 1.02; 95% CI, 0.89–1.16). Conclusions Cardiovascular volume decreased during COVID‐19. Despite similar patient age and comorbidities and in‐hospital treatments during COVID‐19, mortality increased for patients with AMI but not patients with HF. Given that AMI is a time‐sensitive condition, delay or deferral of care rather than changes in hospital care delivery may have led to worse cardiovascular outcomes during COVID‐19. 

Impact of the COVID‐19 Pandemic on Patients Without COVID‐19 With Acute Myocardial Infarction and Heart Failure

Background Excess mortality from cardiovascular disease during the COVID‐19 pandemic has been reported. The mechanism is unclear but may include delay or deferral of care, or differential treatment during hospitalization because of strains on hospital capacity. Methods and Results We used emergency department and inpatient data from a 12‐hospital health system to examine changes in volume, patient age and comorbidities, treatment (right‐ and left‐heart catheterization), and outcomes for patients with acute myocardial infarction (AMI) and heart failure (HF) during the COVID‐19 pandemic compared with pre‐COVID‐19 (2018 and 2019), controlling for seasonal variation. We analyzed 27 427 emergency department visits or hospitalizations. Patient volume decreased during COVID‐19 for both HF and AMI, but age, race, sex, and medical comorbidities were similar before and during COVID‐19 for both groups. Acuity increased for AMI as measured by the proportion of patients with ST‐segment elevation. There were no differences in right‐heart catheterization for patients with HF or in left heart catheterization for patients with AMI. In‐hospital mortality increased for AMI during COVID‐19 (odds ratio [OR], 1.46; 95% CI, 1.21–1.76), particularly among the ST‐segment–elevation myocardial infarction subgroup (OR, 2.57; 95% CI, 2.24–2.96), but was unchanged for HF (OR, 1.02; 95% CI, 0.89–1.16). Conclusions Cardiovascular volume decreased during COVID‐19. Despite similar patient age and comorbidities and in‐hospital treatments during COVID‐19, mortality increased for patients with AMI but not patients with HF. Given that AMI is a time‐sensitive condition, delay or deferral of care rather than changes in hospital care delivery may have led to worse cardiovascular outcomes during COVID‐19.

https://www.ahajournals.org/doi/pdf/10.1161/JAHA.121.022625

The COVID-19 pandemic has led to numerous negative implications for all aspects of society. Although COVID-19 is a predominant lung disease, in 10–30% of cases, it is associated with cardiovascular disease (CVD). The presence of myocardial injury in COVID-19 patients occurs with a frequency between 7–36%. There is growing evidence of the incidence of acute coronary syndrome (ACS) in COVID-19, both due to coronary artery thrombosis and insufficient oxygen supply to the myocardium in conditions of an increased need. The diagnosis and treatment of patients with COVID-19 and acute myocardial infarction (AMI) is a major challenge for physicians. Often the presence of mixed symptoms, due to the combined presence of COVID-19 and ACS, as well as possible other diseases, nonspecific changes in the electrocardiogram (ECG), and often elevated serum troponin (cTn), create dilemmas in diagnosing ACS in COVID-19. Given the often-high ischemic risk, as well as the risk of bleeding, in these patients and analyzing the benefit/risk ratio, the treatment of patients with AMI and COVID-19 is often associated with dilemmas and difficult decisions. Due to delays in the application of the therapeutic regimen, complications of AMI are more common, and the mortality rate is higher.

https://www.mdpi.com/2077-0383/11/11/3024/pdf?version=1653642018

Acute Coronary Syndrome in the COVID-19 Era—Differences and Dilemmas Compared to the Pre-COVID-19 Era

Reports about the influence of the COVID-19 pandemic on the number of hospital admissions and in-hospital mortality during the first wave between March and May 2020 showed conflicting results and are limited by single-center or limited regional multicenter datasets. Aim of this analysis covering all German federal states was the comprehensive description of hospital admissions and in-hospital mortality during the first wave of the COVID-19 pandemic.We conducted an observational study on hospital routine data (§21 KHEntgG) and included patients with the main diagnosis of acute myocardial infarction (ICD 21 and ICD 22). A total of 159 hospitals included 36,329 patients in the database, with 12,497 patients admitted with ST-elevation myocardial infarction (STEMI) and 23,832 admitted with non-ST-elevation myocardial infarction (NSTEMI). There was a significant reduction in the number of patients admitted with STEMI (3748 in 2020, 4263 in 2019 and 4486 in 2018; p < 0.01) and NSTEMI (6957 in 2020, 8437 in 2019 and 8438 in 2020; p < 0.01). These reductions were different between the Federal states of Germany. Percutaneous coronary intervention was performed more often in 2020 than in 2019 (odds ratio 1.13, 95% confidence interval [CI] 1.06-1.21) and 2018 (odds ratio 1.20, 95% CI 1.12-1.29) in NSTEMI and more often than in 2018 (odds ratio 1.26, 95% CI 1.10-1.43) in STEMI. The in-hospital mortality did not differ between the years for STEMI and NSTEMI, respectively.In this large representative sample size of hospitals in Germany, we observed significantly fewer admissions for NSTEMI and STEMI during the first COVID-19 wave, while quality of in-hospital care and in-hospital mortality were not affected. Admissions for STEMI and NSTEMI during the months March to May over 3 years and corresponding in-hospital mortality for patients with STEMI and NSTEMI in 159 German hospitals. (p-value for admissions 2020 versus 2019 and 2018: < 0.01; p-value for mortality: n.s.). 

/pdf/effects-of-the-covid-19-pandemic-on-acute-coronary-syndromes-1dp9eb36.pdf

Effects of the COVID-19 pandemic on acute coronary syndromes in Germany during the first wave: the COVID-19 collateral damage study

The SARS-CoV-2-Pandemic reaching Germany in March 2020 led to a nation-wide lockdown with serious restrictions on public life. Based on the experiences of the tsunami-like waves of infections in other European countries, Germany was preparing for a massive load of severe COVID-19-cases by increasing the number of intensive-care-beds and by cancelling the majority of elective medical procedures to provide as many hospital beds as possible. We conducted a retrospective review of ACS-admissions to the Heart Center Ludwigshafen, an academic tertiary heart center in Germany (using ICD-codes I20.0; I21.0, I21.1 and I21.4). We compared the period March 1st to April 21st in 2020 with the same time period in the years 2017–2019 as reference. We did the same analysis for January and February 2017–2020 to show average numbers of ACS cases over the years. During the COVID-19 lockdown in Germany in March/ April 2020, we observed unchanged numbers for STEMIadmissions, but a significant 50% reduction in NSTE-ACS, in both UA and NSTEMI (Fig. 1). Similar findings were previously reported in Austria and Italy [1, 2]. We compared patient characteristics of ACS patients during the COVID-lockdown with the same time period of the year 2019 (Table 1). We did not find any relevant differences in the patient characteristics during the COVID-lockdown as compared to the year before. The current data do not provide any indication of who of the ACS population was not admitted to the hospital during the COVID-lockdown. We provide data on troponin values of all NSTEMI patients for the two time periods in 2019 and 2020 in the table. The troponin values reported are the maximal values on the first 2 days after admission for the acute event. The median troponin values during the COVID-lockdown were slightly higher as compared to the values from 2019, but significance was not reached (Table 1). Possible explanations for this important observation might be system-related as well as patient-related. By concentrating on the preparation for the COVID-19-pandemic with all necessary efforts undertaken to care for the isolation and treatment of suspected or confirmed cases, established integrated care systems for other acute diseases with well-defined patient pathways might have been neglected. Besides, the lockdown isolated many patients at risk for cardiovascular events and the quarantine of patients with suspected or confirmed SARS-CoV-2-infection at home sometimes might have prevented them from contacting their doctors. The acute presentation of STEMI with severe chestpain probably still triggers the direct transportation to the cathlabs with no changes of admissions. Due to the attention to the plethora of possible symptoms of the SARS-CoV2-infection described in the media, some patients may have mis-interpreted their NSTE-ACS symptoms such as dyspnea and chest pain as possible COVID-19-symptoms rather than as cardiovascular symptoms. As an early invasive treatment of NSTEMI-patients is associated with an improved outcome [3, 4], we might face a higher mortality by non-treated ACS patients as a collateral damage of the COVID-19-era. We, therefore, should take care about reinforcing the already established patient pathways ensuring the access to emergency cardiology care of those patients separated from the access to hospital care for COVID-19-infections that will continue to accompany us in the future until an effective vaccine is developed, to avoid undertreatment of NSTE-ACS-patients.

/pdf/collateral-damage-of-covid-19-lockdown-in-germany-decline-of-2b3guw1lra.pdf

Collateral damage of COVID-19-lockdown in Germany: decline of NSTE-ACS admissions.

P2724Inhospital mortality in patients with infarct-relaled cardiogenic shock undergoing coronary angiography treated with and without acute revascularization therapy

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Collateral damage of COVID-19-lockdown in Germany: decline of NSTE-ACS admissions.

P2724Inhospital mortality in patients with infarct-relaled cardiogenic shock undergoing coronary angiography treated with and without acute revascularization therapy